- Open Access
Recruiting participants to walking intervention studies: a systematic review
International Journal of Behavioral Nutrition and Physical Activity volume 8, Article number: 137 (2011)
Most researchers who are conducting physical activity trials face difficulties in recruiting participants who are representative of the population or from specific population groups. Participants who are often the hardest to recruit are often those who stand to benefit most (the least active, from ethnic and other minority groups, from neighbourhoods with high levels of deprivation, or have poor health). The aim of our study was to conduct a systematic review of published literature of walking interventions, in order to identify the impact, characteristics, and differential effects of recruitment strategies among particular population groups.
We conducted standard searches for studies from four sources, (i) electronic literature databases and websites, (ii) grey literature from internet sources, (iii) contact with experts to identify additional "grey" and other literature, and (iv) snowballing from reference lists of retrieved articles. Included studies were randomised controlled trials, controlled before-and-after experimental or observational qualitative studies, examining the effects of an intervention to encourage people to walk independently or in a group setting, and detailing methods of recruitment.
Forty seven studies met the inclusion criteria. The overall quality of the descriptions of recruitment in the studies was poor with little detail reported on who undertook recruitment, or how long was spent planning/preparing and implementing the recruitment phase. Recruitment was conducted at locations that either matched where the intervention was delivered, or where the potential participants were asked to attend for the screening and signing up process. We identified a lack of conceptual clarity about the recruitment process and no standard metric to evaluate the effectiveness of recruitment.
Recruitment concepts, methods, and reporting in walking intervention trials are poorly developed, adding to other limitations in the literature, such as limited generalisability. The lack of understanding of optimal and equitable recruitment strategies evident from this review limits the impact of interventions to promote walking to particular social groups. To improve the delivery of walking interventions to groups which can benefit most, specific attention to developing and evaluating targeted recruitment approaches is recommended.
It is over a decade since Professors Jerry Morris and Adrienne Hardman described walking as the 'nearest activity to perfect exercise' (Hardman & Morris, p328, 1997) . The epidemiological research underpinning their statement has rapidly increased, so that the promotion of walking is now a central pillar in many international physical activity strategies and national plans, e.g. 2010 Toronto Charter for Physical Activity . Regular walking, independent of other physical activity, can reduce the risk of overall mortality, of cardiovascular disease (CVD) and improve risk factors for CVD, including diastolic blood pressure and lipid profiles [3–5]. Regular walking is associated with a reduction in body mass index and body weight, with reduced risk of type 2 diabetes  and is suggested to improve self esteem, relieve symptoms of depression and anxiety, and improve mood [7, 8]. From a public health perspective, enabling an increase in overall population levels of physical activity through walking will produce an effective reduction in risk of all cause mortality .
A systematic review of the effectiveness of walking interventions found evidence for a range of approaches . These included brief advice to individuals, remote support to individuals, group-based approaches, active travel and community level approaches. Recent reviews have provided evidence to support environmental and school based travel interventions [10–12]. Despite the evidence for the benefits of walking for health, population rates of walking and overall physical activity remain low and below recommended levels [13–15]. Population surveys report that walking behaviour is socially patterned by gender, age, socio-economic status (SES) and by the purpose of walking i.e. for leisure or transport. For example, in the UK long brisk paced walks are more common among affluent groups, whereas walking for transport is more common among less affluent groups [14, 16].
One criticism of the evidence base for walking interventions is a failure to recruit specific groups of the population and further studies are needed to broaden the reach of walking interventions [10–12]. Intervention reach, or recruiting specific population sub-groups, is only partially reflected in public health and clinical research. For example the RE-AIM framework is designed to guide the implementation of behaviour change interventions . It recommends assessing both an intervention's effectiveness and ability to reach a targeted group. Similarly, recent CONSORT (2010) guidelines  recommend clearly displaying the flow of participants throughout a study. Despite identifying recruitment as part of their framework, the guidelines do not define the actions needed to identify and recruit potential populations of participants. There is an absence of conceptual frameworks for recruitment to intervention studies and also a lack of procedural models and systems for recruitment. There is a need to identify what factors are effective in engaging participation at the recruitment phase [19–21].
Research examining recruitment practice has focused on drug or medical interventions rather than public health interventions . Little is known about recruitment to physical activity interventions. A Cochrane review identified three stages of recruitment (invitation, screening, intervention starting) for potential participants into physical activity randomised control trials (RCTs). The authors noted a considerable loss of participants across each stage limiting the effectiveness of interventions . The CONSORT (2010) guidelines, suggest that studies report the number of eligible participants prior to randomisation but do not insist on the need to report the original overall number of responders invited to participate (prior to eligibility) .
Clearly the effectiveness of a walking programme is limited by not only its efficacy of dose (how well the intervention works on its participants) but also by its recruitment (maximising the numbers who will participate and receive the intervention dose). In response to frequent research calls to evaluate effective approaches to the recruitment of individuals to walking studies, the Scottish Physical Activity Research Collaboration http://www.sparcoll.org.uk undertook a series of studies to examine recruitment strategies for research and community based programmes of walking promotion. We defined recruitment for such walking studies or programmes as the process of inviting participation to a formal activity including the invitation, informing and facilitation of interested parties to take part in an organised study, activity or event. This paper reports the results of a systematic review to examine the reported recruitment procedures of walking studies, in order to identify the characteristics of effective recruitment, and the impact and differential effects of recruitment strategies among particular population groups.
Identification of studies
We used The Quality of Reporting of Meta-analysis statement (QUOROM) to provide the structure for our review . We identified four possible sources of potential studies, (i) electronic literature databases and websites, (ii) grey literature from internet sources, (iii) contact with experts to identify additional "grey" and other literature, and (iv) snowballing from reference lists of retrieved articles. In the first stage of the literature search, titles and abstracts of identified articles were checked for relevance. In the second stage, full-text articles were retrieved and considered for inclusion. In the final stage, the reference lists of retrieved full-text articles were searched and additional articles known to the authors were assessed for possible inclusion. We conducted a systematic search of electronic databases including OVID MEDLINE, EMBASE, PsychINFO, PubMed, Scopus, SIGLE and SPORTDiscus. We searched a number of web based databases including National Institute of Health and Clinical Excellence (NICE), Effective Public Health Project (EPHP Hamilton), Health Evidence Canada, and the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI)). We conducted searches of internet sites of key international walking promotion agencies including Walk England, the Centers for Disease Control and Prevention (CDC) and the World Health Organisation (WHO).
Studies published from the end of 2000 up to and including the search date (05/2009) were considered for inclusion. Individualized search strategies for the different databases included combinations of the following key words: (walk*) AND (recruit* OR participat* OR market*). Articles published or accepted for publication in refereed journals were considered for the review. Articles reported in UK grey and web based literature including any evidence of types of recruitment approaches and strategies, any evidence of effectiveness, economic costs, and evidence of any differential response to recruitment approaches were also considered in the review. Conference proceedings and abstracts were included if further searching of the databases or contact with the author was able to retrieve a full article from the study presented in the original piece of literature. We sent emails to international experts, identified in a previous systematic review on walking promotion .
Criteria for study inclusion/exclusion
Titles, abstracts and reports were independently assessed (by AM, CF and GB) for inclusion. Studies were considered to be eligible for inclusion according to the following criteria: (i) participants were of any age and were not trained athletes or sports students, (ii) studies of any type including randomised controlled trials, controlled before-and-after experimental or observational studies, (iii) studies that examined the effects of an intervention to encourage people to walk independently or in a group setting, (iv) interventions of any kind and in any field, whether targeted on individuals, communities, settings, groups or whole populations, (v) details of methods of recruitment were reported or were retrievable through correspondence with the authors, (vi) qualitative studies that examined the experiences of the participants during recruitment and which aimed to assess the effectiveness of the recruitment methods used, and (vii) studies published in English.
Included studies were categorised by study design using standardised criteria for quantitative experimental or observational studies (e.g. RCT, non-Randomised Control Trials (NRCT), before-and-after, cross-sectional), or qualitative studies (e.g. focus groups) .
Criteria for assessment of study quality in relation to recruitment
Two authors (GB and CF) independently assessed the quality of the studies in relation to recruitment description that met the inclusion criteria. The criteria for assessing the recruitment reporting quality of each study were adapted from Jadad (1998) , and in consultation with experts. A formal quality score for each study was completed on a 5-point scale by assigning a value of 0 (absent or inadequately described) or 1 (explicitly described and present) to each of the following questions listed: (i) did the study report where the population was recruited? (ii) did the study report who conducted the recruitment? (iii) did the study report the time spent planning/preparing the recruitment? (iv) did the study report the time spent conducting the recruitment? (v) did the study target a specific population? Studies that scored 4-5 were considered as high quality studies while studies that scored 1-3 were considered low quality.
Criteria for assessing efficiency and effectiveness
Where possible we calculated recruitment rates and efficiency ratios for each study, based on a previous systematic review of interventions to promote physical activity . We defined four terms, (i) "pool"-the total number of potential participants who could be eligible for study, (ii) "invited"-the total number of potential participants invited to participate in the study, (iii) "responded"-the total number of potential participants who responded to the invitation, (iv) "started"-the number of participants who were assessed as eligible to participate and began the programme. If data were reported we calculated ratios for each stage, e.g. started/pool-by dividing the number of participants who started into the study by the total reported in the pool, and expressed as proportions. If possible we attempted to calculate a weekly rate of recruitment for those studies on the number of weeks/months spent recruiting per participant.
Fifty three papers representing 47 studies met our inclusion criteria. Duplicate studies were excluded and the journal article reporting the most recruitment data was analysed. The flow of studies through the review process is reported in Figure 1. Characteristics of included studies are presented in Table 1, ranked by quality score. Each included paper is referenced in the results and discussion sections in superscript, using their Study Number presented in Table 1. Full references for included papers are listed in additional file 1 and are presented in this paper in superscript form. Studies were located in the USA (24) [27–50], Australia (11) [51–61], UK (7) [62–68], Canada (3) [69–71], and one each from New Zealand  and Belgium . Nearly all the studies were quantitative experimental studies in design, with twenty six randomised controlled trials, [4, 27, 28, 32–34, 36–38, 42, 43, 46, 47, 49, 52, 54, 56, 58, 62–67, 70] two studies reporting methods only [28, 35], three non-randomised controlled trials [31, 41, 73] and seventeen before-and-after studies [27, 29, 30, 39, 40, 44, 45, 48, 50, 51, 53, 55, 59–61, 68, 71] (two reporting methods only) [27, 30]. We found only two qualitative studies reporting on recruitment approaches [57, 69], with one paper reporting qualitative data as part of an RCT study . No studies were located from grey literature sources.
Overview of study quality in relation to recruitment
Eight studies were classified as "high" quality [27–30, 51, 62, 69, 72] and the remaining thirty nine classified as "low" quality in relation to recruitment description (Table 2-Assessment of study quality). Forty five studies reported a setting where the recruitment of participants took place [27–49, 51–67, 69–73] but only twenty two reported who conducted the recruitment [27–31, 33, 35–40, 45, 51–54, 62, 64, 65, 69, 72]. Eleven studies reported the time spent conducting their recruitment [27–30, 32, 51, 62, 63, 66, 70, 72] three studies reported the time spent planning/preparing recruitment [34, 51, 69]. Forty studies reported a target population [27–45, 48, 50–60, 62–65, 68–70, 72, 73].
Characteristics of the participants
Thirty seven studies reported participant ages [28–30, 32–47, 49, 51–54, 56, 58, 59, 62–67, 70–73] with a mean age of 50.6 years, (SD ± 8.1 years), and a range of 18 to 92 years (Table 3-Characteristics of participants). Sixteen out of forty two studies that reported gender data focused on recruiting female only participants [27, 29, 30, 32, 35–37, 41–44, 46, 51, 52, 55, 68, 70], with one study recruiting men only . From the remaining twenty five studies that did not recruit sex specific groups, 70% (SD ± 20.8) of participants were female. Twenty two studies reported data on nationality and ethnicity, of which seventeen reported descriptive statistics for ethnicity or race [27–38, 40–42, 46, 49, 51, 54, 58, 68, 70, 71]. Three studies reported targeting one specific ethnic group, African-Americans [27, 30, 40]. Of the remaining studies, twelve reported other ethnicity data; 87% of these participants were white Caucasian [28, 31–34, 36, 38, 41, 43, 49, 70, 71]. Additional socio-demographic data (SES or income groups, education, urban/rural living and relationship status) were reported but not consistently across all studies. Seven studies reported data on participant's income level data, which tended to be higher than average [28, 30, 31, 38, 42, 49, 68]. Sample sizes of the studies ranged from 9 to 1674 participants.
Recruitment data reported
Two studies reported all data for all components of recruitment, i.e. where recruitment took place; who conducted the recruitment; the time taken to conduct the planning/preparing and delivery stages [27, 51]. Thirty nine studies did report a specified target group (Table 4-Recruitment planning/preparing and implementation). Forty four studies provide some details of where recruitment was conducted [27–49, 51–56, 58–67, 69–73] but the recruitment location was often given vague descriptions, for example "in the community". Most popular were medical/care settings (n = 12) [29–31, 33, 34, 36, 38, 43, 49, 51, 55, 63] or universities (n = 9) [37, 40, 41, 43, 44, 46, 47, 62, 70]. Other community settings included for example, places of worship , hair salons , food establishments [29, 71] or specific events within such settings, for example meetings for new mothers .
Twenty one studies reported who conducted the study recruitment. Most popular recruiters were research staff [28, 31, 33, 34, 37, 39, 51, 52, 54, 62, 64, 67, 72], often with assistance from health professionals like doctors or nurses [29, 33, 51, 65]. Five studies reported using a dedicated "recruitment specialist" [27, 30, 35, 51, 69]. Only three studies reported the time spent planning/preparing their recruitment phases [34, 51, 69]. Eleven studies reported the time spent on implementing recruitment [27–30, 32, 51, 62, 63, 71, 72] and this averaged as 35 weeks, with a range of 2 days to 56 weeks.
Recruitment procedures and approaches
The reporting of recruitment methods was often sparse and unstructured (Table 5-Number of methods and types of recruitment procedures). Forty five studies provided data on the number of recruitment methods used (mean 2.7, SD 1.97). Sixteen studies relied on one method of recruitment only [33, 34, 43–45, 50–53, 56, 58, 60, 62, 64, 65, 72], and 26 studies used between two and four methods [27–32, 35–41, 54, 55, 63, 66, 69–71, 73]. We identified two types of recruitment approaches, (i) active approaches; a recruitment method that requires those conducting the study to make the first contact with a participant (e.g. phone calls, face to face invitation, word of mouth, referrals), (ii) passive approaches; a recruitment method that requires a potential participant makes the first contact with the study (e.g. posters, leaflets drops, newspaper advertisements, mail outs). We did not observe any relationship between the quality of recruitment reporting and the number of recruitment strategies used. We did however observe that a number of studies used only passive techniques (n = 21) [32, 34, 38, 41, 42, 44, 46–48, 52, 54, 56, 58–62, 64, 66, 67, 70], some used a mixture of active and passive techniques (n = 22) [27–31, 33, 35–37, 39, 40, 49, 53, 55, 57, 63, 65, 68, 69, 71–73] and a small number used solely active only methods (n = 4) [43, 45, 50, 51].
Passive recruitment methods, which require no interaction with the potential participants, were popular (Figure 2). Flyers/posters/advertisements/mail drops were the most cited approach used, appearing in 31 studies. This was almost twice as prevalent as the second most popular approach, newsletters/newspaper articles (n = 18) and was nearly three times more frequently used than word of mouth. Word of mouth appeared in 12 studies, but we were unable to identify whether this was a proactive recruitment strategy or a reactive strategy, responding to low recruitment numbers. Less popular methods included medical and health insurance referral, invitations derived from clinical or employment data, study information sessions, resident listings, announcements at group meetings or community events and information stands.
Locations for recruitment, interventions and target populations
Table 6 presents data on the setting and location of recruitment and the study. We observed some studies that "matched" where the recruitment was conducted with where the intervention was delivered. Culos-Reed et al, 2008 reported recruiting participants for a mall walking study at the mall where the intervention was going to be delivered . Other studies did not match in this way, and recruited in many different locations, often relying on print material alone, and requiring potential participants to attend a location which may not be easily accessible to them. Studies reported that they were "community-based" (n = 25) [27–31, 35, 36, 42, 48–52, 54–58, 61, 63, 68, 69, 71–73] but asked community members to travel into a research setting to begin the process of participation; for example medical centres or universities (n = 20) [29, 30, 33–38, 41, 43, 46, 47, 49, 56, 62–67]. These interventions used a mixture of recruitment approaches including media events and led walking groups, face to face interventions (e.g. counselling, pedometers) or mediated interventions, such as internet, e-health and mobile phone technology .
Recruitment rates and efficiencies
We originally planned to calculate recruitment rates and efficiency ratios for each study but we were unable to do so due to missing data (Table 7-Recruitment rates and efficiency ratios). Only three studies provided all the data points [33, 36, 65]. We were able to calculate a weekly recruitment rate using the final numbers of participants divided by the time spent recruiting in weeks for eleven studies (mean 38 participants per week, range 1 to 268 participants per week). We were not able to see any pattern between recruitment approaches and weekly rates. Two studies reported some data on the efforts needed to undertake recruitment. Jancey et al (2008) reported that after potential participants had received invitation cards it took approximately 9 calls to recruit one participant .
Developing Recruitment Approaches
We identified factors that may have helped or hindered recruitment from qualitative [57, 64, 69] and protocol [27, 28, 30, 35] papers. These factors emerged as possible principles of recruitment and were related to training, engaging possible participants in the recruitment process and allowing sufficient time to pilot-test approaches. Watson et al (2009) used trained post-natal health care staff to actively recruit participants during their first home and health centres visits, and at group meetings for new mothers . Recruitment approaches used by Banks-Wallace et al (2004) were based on a 5 month needs assessment study of the concerns and priorities of their target group . The authors reported this process established trust between the research team and participants and ensured active participation in the study and in fact over-recruited from this population. Nguyen et al (2002) reported promoting participation via word of mouth, e.g. one participant tells/recruits another participant . These appeared to have more impact on recruitment than passive approaches like posters or media stories . These data suggest that developing recruitment approaches is a time and resource intensive activity, requiring skilled research and recruitment staff.
We conducted a systematic review to examine the reported recruitment procedures of walking studies, in order to identify the characteristics of effective recruitment and the impact and differential effects of recruitment strategies among particular population groups. We identified the need for a common understanding of the recruitment process for walking studies in terms of conceptual definition, defining effectiveness and more detailed reporting. Due to the heterogeneity of studies we were not able to identify what specific recruitment approaches were most successful with particular population groups.
We identified eighteen recruitment strategies from 47 studies but did not see any relationship between one particular strategy or group of strategies and recruitment rates. Many studies blended different recruitment approaches and strategies, adopting an almost "trial and error" approach. Only two studies reported the effectiveness of their approaches to recruitment [28, 35]. We were able to distinguish active and passive recruitment approaches. Further research is needed to directly compare specific recruitment strategies.
Very few studies examined the successes of recruitment approaches to physical activity interventions. Harris et al (2008) conducted a randomized controlled trial of four recruitment strategies in their physical activity promotion intervention study for older adults . The authors reported that telephone follow up a week post invitation significantly increased recruitment compared to invitation only. Certainly the principle of follow up was found in a number of our included studies [53, 63, 72] but we could not assess the efficacy of these strategies. The efficacy of phone recruitment has been questioned by Margitic et al (1999)  who compared three recruitment strategies for Project ACT: patient mailings, office-based questionnaires and telephone contact. However their participants were not randomized to a particular strategy. The authors also reported that despite telephone recruitment appearing to be productive this strategy was dropped in two out of eight recruitment sites on cost grounds. This behavioural approach of using phone follow up has previously been reported to be more effective than no follow up in changing physical activity and walking behaviour [10, 23] and certainly warrants further testing in terms of a possible recruitment strategy.
Tai and Iliffe's (2000) experiences of conducting physical activity studies also support our observation that piloting and pre-testing of recruitment methods would improve rates of recruitment and precision in recruiting specific target groups . Our review clearly shows that current recruitment strategies resulted in recruiting mostly white, well-educated, middle aged women. The attraction of walking projects to particular social groups has also been reported in previous evaluation studies of community walking programmes both in the UK  and USA [27, 31]. Our review found that recruitment rates were poorer for men, especially within workplace or community settings but we were unable to determine if it is a fault of the recruitment, or the offer of walking or a combination of both that is at fault.
We identified a number of studies that "matched" where the recruitment was conducted, with where the intervention was delivered. This principle supports the notion that connecting the place of recruitment and intervention may be more efficient both for the participants, recruiters and interventions teams. We found studies that did not effectively match these aspects and perhaps this was reflected in the total number of participants recruited and the longer time it took to conduct their recruitment phase. For example, Baker et al (2008) reported that participants were expected to travel to the university to receive their intervention. We found little data on the time spent planning/preparing and implementing recruitment so any potential learning from recruitment remains unreported .
We identified a number of studies that also aimed to match those recruiting with those being recruited. Banks-Wallace et al (2004) reported in detail their use of a recruitment mediator . The mediator was the same gender as the target group, was a prominent local figure, trained in delivering community interventions and female. Her role was to introduce the study to key significant figures in the area and increase awareness, to assist directly with the recruitment phase and to introduce the researchers to the potential participants at an information session. Banks-Wallace et al (2004) described this approach as increasing trust and decreasing differences between the recruiters and recruited .
Our review clearly found there was very little consistency in the definition or reporting of recruitment. We found many different interpretations of (i) what is the recruitment process? and (ii) what is an appropriate metric for evaluating the effectiveness of recruitment? The lack of conceptual clarity about recruitment as a process is surprising and potentially impacts on cost-effectiveness. The RE-AIM framework emphasises the need to judge the success of an intervention from both the reach and uptake of an intervention . In light of this we constructed a conceptual framework for our review by defining the stages of recruitment and potential pool of participants (Figure 3). This framework offers a starting point for further debate and refinement. The framework offers a clear concept of the stages and steps of recruitment and the chance to record the numbers of participants at each stage and action.
Our framework divided recruitment into two phases, planning/preparing and implementation, with four stages involving discrete actions by researchers/recruiters, (i) identification of participant pools, (ii) invitation and monitor response and uptake, (iii) assessment, screening and facilitation and (iv) re-invitation of responders, before the delivery of intervention to starters. This framework highlights the actions needed at the start of a recruitment process, i.e. planning/preparing the recruitment process. It also emphasises the importance of the reach of an intervention i.e. the pool of participants used to provide recruits. This differs from the recent new CONSORT framework which asks for dates of recruitment period (i.e. delivery) and enrolment stage . CONSORT stipulates data must be reported for numbers of participants eligible for study which we feel not only ignores the overall pool of possible participants, especially in community based studies of walking interventions, but also ignores the population deemed ineligible, as seen in pre-screenings of patient lists for existing conditions . The "pool" of participants perhaps provides a more realistic denominator for assessing overall recruitment rates. This metric will allow new studies to (i) consider if the recruitment was efficient (i.e. study recruited expected numbers of participants) and/or (ii) consider if it was effective (i.e. study recruited the right target group), and/or (iii) reflect the true costs of all recruitment actions within overall cost benefit calculations. The need for better reporting of recruitment actions and numbers is essential to improve the assessment of present recruitment strategies. This view is mirrored in recruitment studies of other health behaviours, and better reporting must begin before we can start to identify which strategies provide the best recruitment rates .
The results of our review were limited to walking intervention studies. We were limited by only including studies written in the English language. We were limited by what was reported in papers but our consistent application of inclusion, quality and data extraction criteria have illustrated the need for improvement in both the reporting and science of recruitment. As journals look to keep research reports within word limits, it is likely that there will continue to be a lack of journal space to report recruitment details, and we would like to call on editors and authors to report recruitment details or provide short methods papers for the insight of future researchers. As far as we are aware this review is the first of its kind focusing on one domain of physical activity behaviour. The lack of understanding and studies into recruitment may reflect some of the findings about the existing weaknesses of the evidence base for walking interventions, e.g. lack of generalisability of interventions across different social groups .
The evidence base for the benefits of walking is now expanding but until it is clearer what strategies are effective in both recruiting and initiating people to begin walking, such benefits may be out of reach for particular population groups. Practitioners would benefit from the assurance of having an evidence based best practice model which details how best to recruit participants as well as what is the best intervention to promote walking. Our conceptual framework offers researchers, practitioners and policy makers a way forward to develop and assess the success of a recruitment strategy to target particular groups. The model offers options through the four stages to assess how many people are responding and engaging in a walking intervention, but also whether any bias is occurring and if efforts need to be refined towards a specific group. It could also provide a true picture of the costs of the intervention as the inclusion of recruitment development and implementation should be included in economic evaluations.
The results of our review could translate into a series of recruitment principles for further evaluation by researchers. These principles include (i) form recruitment plans and strategies on evidence of what the target group feels would be appropriate, based on formative research, (ii) conduct a pilot phase of testing, (iii) recruit in places where the participants are located, (iv) allow sufficient time to recruit participants and monitor the uptake, (v) provide training in recruitment methods for recruitment staff, (vi) monitor the participants response to recruitment approaches and use different recruitment strategies where necessary.
The future of walking and physical activity promotion will lie not only in establishing the effectiveness of different interventions but also in improved recruitment practice. Currently, generalisability is limited by reach within studies; but while the current methods being used are applied, the current limited reach will prevail. We offer principles for recruitment that require further evaluation, (i.e. matching "where to where" and "who to who"). Future research to identify "what is effective recruitment?" may best lie in identifying approaches that reflect the needs and expectations of hard to recruit target groups. This will allow researchers the opportunity to investigate the strategic use of the right recruitment methods, for the right group, in the right order.
Hardman AE, Morris JN: Walking to health. Sports Med. 1997, 23: 306-332. 10.2165/00007256-199723050-00004.
Global Advocacy Council for Physical Activity ISfPAaH: The Toronto Charter for Physical Activity: A Global Call for Action. J Phys Act Health. 2010, 7 (Suppl 3): S370-385.
Committee PAGA: Physical Activity Guidelines Advisory Committee Report, 2008. 2008, Washington, DC: US Department of Health and Human Services
Lee IM, Skerrett PJ: Physical activity and all-cause mortality: what is the dose-response relation?. Med Sci Sports Exerc. 2001, 33: S459-471. 10.1097/00005768-200106001-00016. discussion S493-454
Murphy MH, Nevill AM, Murtagh EM, Holder RL: The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials. Prev Med. 2007, 44: 377-385. 10.1016/j.ypmed.2006.12.008.
Hu FB, Sigal RJ, Rich-Edwards JW, Colditz GA, Solomon CG, Willett WC, Speizer FE, Manson JE: Walking compared with vigorous physical activity and risk of type 2 diabetes in women: a prospective study. Jama. 1999, 282: 1433-1439. 10.1001/jama.282.15.1433.
Department of Health PA, Health Improvement and Prevention: At least five a week: Evidence on the impact of physical activity and its relationship to health. A report from the Chief Medical Officer. Book At least five a week: Evidence on the impact of physical activity and its relationship to health. A report from the Chief Medical Officer. 2004, City, ed.^eds
MIND: The MIND guide to physical activity. 2008, London: MIND
Hamer M, Chida Y: Walking and primary prevention: a meta-analysis of prospective cohort studies. Br J Sports Med. 2008, 42: 238-243. 10.1136/bjsm.2007.039974.
Ogilvie D, Foster CE, Rothnie H, Cavill N, Hamilton V, Fitzsimons CF, Mutrie N: Interventions to promote walking: systematic review. BMJ. 2007, 334: 1204-10.1136/bmj.39198.722720.BE.
Excellence NIfHaC: Promoting and creating built or natural environments that encourage and support physical activity (NICE public health guidance 8). 2008, London: NICE
Excellence NIfHaC: Promoting physical activity for children and young people. 2009, London: NICE
Bauman A, Bull F, Chey T, Craig CL, Ainsworth BE, Sallis JF, Bowles HR, Hagstromer M, Sjostrom M, Pratt M: The International Prevalence Study on Physical Activity: results from 20 countries. Int J Behav Nutr Phys Act. 2009, 6: 21-10.1186/1479-5868-6-21.
Centre TI: Health Survey for England 2008: Physical activity and fitness. Summary of key findings. Book Health Survey for England 2008: Physical activity and fitness. Summary of key findings. 2009, City, ed.^eds
Executive S: The Scottish Health Survey 2008. 2008, Edinburgh: The Stationery House
Transport Df: Transport Statistics Bulletin: National Travel Survey 2008. Book Transport Statistics Bulletin: National Travel Survey 2008. 2009, City: Department for Transport, ed.^eds
Glasgow RE, Vogt TM, Boles SM: Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999, 89: 1322-1327. 10.2105/AJPH.89.9.1322.
Schulz KF, Altman DG, Moher D: CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ. 2010, 340: c332-10.1136/bmj.c332.
Swanson GM, Ward AJ: Recruiting minorities into clinical trials: toward a participant-friendly system. J Natl Cancer Inst. 1995, 87: 1747-1759. 10.1093/jnci/87.23.1747.
Froelicher ES, Lorig K: Who cares about recruitment anyway?. Patient Educ Couns. 2002, 48: 97-10.1016/S0738-3991(02)00168-4.
Treweek S, Pitkethly M, Cook J, Kjeldstrom M, Taskila T, Johansen M, Sullivan F, Wilson S, Jackson C, Jones R, Mitchell E: Strategies to improve recruitment to randomised controlled trials. Cochrane Database Syst Rev. 2010, MR000013.
Toerien M, Brookes ST, Metcalfe C, de Salis I, Tomlin Z, Peters TJ, Sterne J, Donovan JL: A review of reporting of participant recruitment and retention in RCTs in six major journals. Trials. 2009, 10: 52-10.1186/1745-6215-10-52.
Hillsdon M, Foster C, Thorogood M: Interventions for promoting physical activity. Cochrane Database Syst Rev. 2005, CD003180.
Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF: Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet. 1999, 354: 1896-1900. 10.1016/S0140-6736(99)04149-5.
Excellence NIfHaC: Methods for the development of NICE public health guidance (second edition). 2009, London: NICE
Jadad A: Randomised controlled trials; A users guide. 1998, London: BMJ Books
Banks-Wallace J, Enyart J, Johnson C: Recruitment and entrance of participants into a physical activity intervention for hypertensive African American women. ANS Adv Nurs Sci. 2004, 27: 102-116.
Rowland RM, Fishera JK, Greena M, Dunnb AM, Pickeringa MA, Lia F: Recruiting inactive older adults to a neighborhood walking trial: The SHAPE project. Journal of Aging Studies. 2004, 18: 353-368. 10.1016/j.jaging.2004.03.001.
Sherman BJ, Gilliland G, Speckman JL, Freund KM: The effect of a primary care exercise intervention for rural women. Prev Med. 2007, 44: 198-201. 10.1016/j.ypmed.2006.10.009.
Wilbur J, McDevitt JH, Wang E, Dancy BL, Miller AM, Briller J, Ingram DL, Nicola TL, Ju S, Lee H: Outcomes of a home-based walking program for African-American women. Am J Health Promot. 2008, 22: 307-317. 10.4278/ajhp.22.5.307.
Brownson RC, Hagood L, Lovegreen SL, Britton B, Caito NM, Elliott MB, Emery J, Haire-Joshu D, Hicks D, Johnson B, et al: A multilevel ecological approach to promoting walking in rural communities. Prev Med. 2005, 41: 837-842. 10.1016/j.ypmed.2005.09.004.
Dinger MK, Heesch KC, Cipriani G, Qualls M: Comparison of two email-delivered, pedometer-based interventions to promote walking among insufficiently active women. J Sci Med Sport. 2007, 10: 297-302. 10.1016/j.jsams.2006.07.011.
Dubbert PM, Cooper KM, Kirchner KA, Meydrech EF, Bilbrew D: Effects of nurse counseling on walking for exercise in elderly primary care patients. J Gerontol A Biol Sci Med Sci. 2002, 57: M733-740. 10.1093/gerona/57.11.M733.
Dubbert PM, Morey MC, Kirchner KA, Meydrech EF, Grothe K: Counseling for home-based walking and strength exercise in older primary care patients. Arch Intern Med. 2008, 168: 979-986. 10.1001/archinte.168.9.979.
Lee RE, McGinnis KA, Sallis JF, Castro CM, Chen AH, Hickmann SA: Active vs. passive methods of recruiting ethnic minority women to a health promotion program. Ann Behav Med. 1997, 19: 378-384. 10.1007/BF02895157.
Matthews CE, Wilcox S, Hanby CL, Der Ananian C, Heiney SP, Gebretsadik T, Shintani A: Evaluation of a 12-week home-based walking intervention for breast cancer survivors. Support Care Cancer. 2007, 15: 203-211. 10.1007/s00520-006-0122-x.
Ornes LL, Ransdell LB: Web-Based Physical Activity Intervention for College-Aged Women. Percept Mot Skills. 2007, 10: 126-137.
Richardson CR, Mehari KS, McIntyre LG, Janney AW, Fortlage LA, Sen A, Strecher VJ, Piette JD: A randomized trial comparing structured and lifestyle goals in an internet-mediated walking program for people with type 2 diabetes. Int J Behav Nutr Phys Act. 2007, 4: 59-10.1186/1479-5868-4-59.
Rosenberg D, Kerr J, Sallis JF, Patrick K, Moore DJ, King A: Feasibility and outcomes of a multilevel place-based walking intervention for seniors: a pilot study. Health Place. 2009, 15: 173-179. 10.1016/j.healthplace.2008.03.010.
Whitt-Glover MC, Hogan PE, Lang W, Heil DP: Pilot study of a faith-based physical activity program among sedentary blacks. Prev Chronic Dis. 2008, 5: A51.
Dinger MK, Heesch KC, McClary KR: Feasibility of a minimal contact intervention to promote walking among insufficiently active women. Am J Health Promot. 2005, 20: 2-6. 10.4278/0890-1171-20.1.2.
Nies MA, Partridge T: Comparison of 3 interventions to increase walking in sedentary women. Am J Health Behav. 2006, 30: 339-352.
Purath J, Miller AM, McCabe G, Wilbur J: A brief intervention to increase physical activity in sedentary working women. Can J Nurs Res. 2004, 36: 76-91.
Sidman CL, Corbin CB, Le Masurier G: Promoting physical activity among sedentary women using pedometers. Res Q Exerc Sport. 2004, 75: 122-129.
Tudor-Locke CE, Myers AM, Bell RC, Harris SB, Wilson Rodger N: Preliminary outcome evaluation of the First Step Program: a daily physical activity intervention for individuals with type 2 diabetes. Patient Educ Couns. 2002, 47: 23-28. 10.1016/S0738-3991(01)00169-0.
Hultquist CN, Albright C, Thompson DL: Comparison of walking recommendations in previously inactive women. Med Sci Sports Exerc. 2005, 37: 676-683. 10.1249/01.MSS.0000158993.39760.1B.
Lombard DN, Lombard TN, Winett RA: Walking to meet health guidelines: the effect of prompting frequency and prompt structure. Health Psychol. 1995, 14: 164-170.
Rovniak LS, Hovell MF, Wojcik JR, Winett RA, Martinez-Donate AP: Enhancing theoretical fidelity: an e-mail-based walking program demonstration. Am J Health Promot. 2005, 20: 85-95. 10.4278/0890-1171-20.2.85.
Talbot LA, Gaines JM, Huynh TN, Metter EJ: A home-based pedometer-driven walking program to increase physical activity in older adults with osteoarthritis of the knee: a preliminary study. J Am Geriatr Soc. 2003, 51: 387-392. 10.1046/j.1532-5415.2003.51113.x.
Wyatt HR, Peters JC, Reed GW, Grunwald GK, Barry M, Thompson H, Jones J, Hill JO: Using Electronic Step Counters to Increase Lifestyle Physical Activity: Colorado on the Move. J Phys Act Health. 2004, 1: 181-190.
Watson N, Milat AJ, Thomas M, Currie J: The feasibility and effectiveness of pram walking groups for postpartum women in western Sydney. Health promotion journal of Australia: official journal of Australian Association of Health Promotion Professionals. 2005, 16: 93-99.
Cox KL, Burke V, Beilin LJ, Derbyshire AJ, Grove JR, Blanksby BA, Puddey IB: Short and long-term adherence to swimming and walking programs in older women--the Sedentary Women Exercise Adherence Trial (SWEAT 2). Prev Med. 2008, 46: 511-517. 10.1016/j.ypmed.2008.01.010.
Jancey JM, Clarke A, Howat PA, Lee AH, Shilton T, Fisher J: A physical activity program to mobilize older people: a practical and sustainable approach. Gerontologist. 2008, 48: 251-257. 10.1093/geront/48.2.251.
Merom D, Rissel C, Phongsavan P, Smith BJ, Van Kemenade C, Brown WJ, Bauman AE: Promoting walking with pedometers in the community: the step-by-step trial. Am J Prev Med. 2007, 32: 290-297. 10.1016/j.amepre.2006.12.007.
Currie J, Develin E: Factors to consider when designing community pramwalking programs. American Journal of Health Education. 2001, 32: 48-51.
Engel L, Lindner H: Impact of using a pedometer on time spent walking in older adults with type 2 diabetes. Diabetes Educ. 2006, 32: 98-107. 10.1177/0145721705284373.
Assessing the sustainability of the 'Just Walk it' program: Is it effective and will it engance programm success. [http://www.transport.wa.gov.au/conferences/walking/pdfs/B1.pdf]
Humpel N, Marshall AL, Iverson D, Leslie E, Owen N: Trial of print and telephone delivered interventions to influence walking. Prev Med. 2004, 39: 635-641. 10.1016/j.ypmed.2004.02.032.
Shaw G, Alfonso H, Howat P, Corben K: Use of pedometers in a workplace physical activity program. Australasian Journal of Podiatric Medicine. 2004
Thomas L, Williams M: Promoting physical activity in the workplace: using pedometers to increase daily activity levels. Health promotion journal of Australia: official journal of Australian Association of Health Promotion Professionals. 2006, 17: 97-102.
Department NSWH: Walk it: active local parks: the effect of park modifications and promotion on physical activity participation: summary report. Book Walk it: active local parks: the effect of park modifications and promotion on physical activity participation: summary report. 2002, City: NSW Health Department, ed.^eds
Prestwich A, Perugini M, Hurling R: Can implementation intentions and text messages promote brisk walking? A randomized trial. Health Psychol. 2010, 29: 40-49.
Baker G, Gray SR, Wright A, Fitzsimons C, Nimmo M, Lowry R, Mutrie N: The effect of a pedometer-based community walking intervention "Walking for Wellbeing in the West" on physical activity levels and health outcomes: a 12-week randomized controlled trial. Int J Behav Nutr Phys Act. 2008, 5: 44.
Gilson N, McKenna J, Cooke C: Experiences of route and task-based walking in a university community: qualitative perspectives in a randomized control trial. J Phys Act Health. 2008, 5 (Suppl 1): S176-182.
Lamb SE, Bartlett HP, Ashley A, Bird W: Can lay-led walking programmes increase physical activity in middle aged adults? A randomised controlled trial. J Epidemiol Community Health. 2002, 56: 246-252. 10.1136/jech.56.4.246.
Darker CD, French DP, Eves FF, Sniehotta FF: An intervention to promote walking amongst the general population based on an 'extended' theory of planned behaviour: a waiting list randomised controlled trial. Psychol Health. 2010, 25: 71-88. 10.1080/08870440902893716.
Baker G, Mutrie N, Lowry R: Using pedometers as motivational tools: Are goals set in steps more effective than goals set in minutes for increasing walking?. International Journal of Health Promotion and Education. 2008, 46: 21-26.
Rowley C, Dixon L, Palk R: Promoting physical activity: walking programmes for mothers and children. Community Pract. 2007, 80: 28-32.
Nguyen MN, Gauvin L, Martineau I, Grignon R: Sustainability of the impact of a public health intervention: lessons learned from the laval walking clubs experience. Health Promot Pract. 2005, 6: 44-52. 10.1177/1524839903260144.
Arbour KP, Martin Ginis KA: A randomised controlled trial of the effects of implementation intentions on women's walking behaviour. Psychol Health. 2009, 24: 49-65. 10.1080/08870440801930312.
Culos-Reed SN, Stephenson L, Doyle-Baker PK, Dickinson JA: Mall walking as a physical activity option: results of a pilot project. Can J Aging. 2008, 27: 81-87. 10.3138/cja.27.1.81.
Kolt GS, Oliver M, Schofield GM, Kerse N, Garrett N, Latham NK: An overview and process evaluation of TeleWalk: a telephone-based counseling intervention to encourage walking in older adults. Health Promot Int. 2006, 21: 201-208. 10.1093/heapro/dal015.
De Cocker KA, De Bourdeaudhuij IM, Brown WJ, Cardon GM: Effects of "10,000 steps Ghent": a whole-community intervention. Am J Prev Med. 2007, 33: 455-463. 10.1016/j.amepre.2007.07.037.
Napolitano MA, Marcus BH: Targeting and tailoring physical activity information using print and information technologies. Exerc Sport Sci Rev. 2002, 30: 122-128. 10.1097/00003677-200207000-00006.
Harris TJ, Carey IM, Victor CR, Adams R, Cook DG: Optimising recruitment into a study of physical activity in older people: a randomised controlled trial of different approaches. Age Ageing. 2008, 37: 659-665. 10.1093/ageing/afn159.
Margitic S, Sevick MA, Miller M, Albright C, Banton J, Callahan K, Garcia M, Gibbons L, Levine BJ, Anderson R, Ettinger W: Challenges faced in recruiting patients from primary care practices into a physical activity intervention trial. Activity Counseling Trial Research Group. Prev Med. 1999, 29: 277-286. 10.1006/pmed.1999.0543.
Tai SS, Iliffe S: Considerations for the design and analysis of experimental studies in physical activity and exercise promotion: advantages of the randomised controlled trial. Br J Sports Med. 2000, 34: 220-224. 10.1136/bjsm.34.3.220.
Dawson J, Hillsdon M, Boller I, Foster C: Perceived barriers to walking in the neighbourhood environment and change in physical activity levels over 12 months. Br J Sports Med. 2007, 41: 562-568. 10.1136/bjsm.2006.033340.
Klesges LM, Estabrooks PA, Dzewaltowski DA, Bull SS, Glasgow RE: Beginning with the application in mind: designing and planning health behavior change interventions to enhance dissemination. Ann Behav Med. 2005, 66-75. 29 Suppl
Raynor HA, Osterholt KM, Hart CN, Jelalian E, Vivier P, Wing RR: Evaluation of active and passive recruitment methods used in randomized controlled trials targeting pediatric obesity. Int J Pediatr Obes. 2009, 4: 224-232. 10.3109/17477160802596189.
Acknowledgements & funding
We would like to thank the participants and researches who gave their time to provide our data. NM is the principle investigator for The Scottish Physical Activity Research Collaboration (SPARColl) is based at the University of Strathclyde. The collaboration is funded by the Scottish Government and managed by NHS Health Scotland.
The authors would like to acknowledge the SPARColl advisory group for feedback during the study design and manuscript preparation stage. GB's PhD is funded by SPARColl. CF is funded by the British Heart Foundation Project Grant (BHF/PG/03/045).
The authors declare that they have no competing interests.
CF, GB & NM conceived of the study, and participated in its design, coordination and helped to draft the manuscript. CFtz & CMcA participated in its design and coordination and helped to draft the manuscript. CF, GB & AM participated in review screening, data extraction and helped to draft the manuscript. All authors read and approved the final manuscript.
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Cite this article
Foster, C.E., Brennan, G., Matthews, A. et al. Recruiting participants to walking intervention studies: a systematic review. Int J Behav Nutr Phys Act 8, 137 (2011). https://doi.org/10.1186/1479-5868-8-137
- physical activity
- health promotion